Scholarship Application Student Name Current Grade LevelFreshmanSophomoreJuniorSenior Parent(s) and/or Guardian(s) Name Address City State ZIP Parent(s) and/or Guardian(s) Phone Parent(s) and/or Guardian(s) Email Student Phone (if applicable) Student Email Student Demographics Race (select all that apply) American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Other Pacific IslanderWhite / Caucasian I am currently a: High School StudentTrade or Technical SchoolUndergraduate StudentGraduate Student Gender FemaleMale Date of Birth First generation college student? YesNo Immigrant/Refugee/Foreign-born? YesNo Welfare/Workfare Client? YesNo # of family members living in household? Household income? (per most recent tax forms) Δ
